The prospect of sharp curtailment by third party payers of insurance coverage of outpatient private intensive psychotherapy and psychoanalysis has, in the past year or two, stirred much interest, concern, and some confusion about the “facts.” This article surveys the historical background and “reasons” for this development, and reviews some effects on the present and future practice of psychoanalysis arising from the administration of rapidly growing “third party” systems of mental health care delivery in the United States.
The advent in the past twenty years of both commercial and physician-sponsored health insurance programs providing for indirect, third party methods of payment for a significant percentage of the costs of privately contracted outpatient psychiatric treatment has permanently modified the traditional two-party payment arrangement. In particular, passage of the Federal Employees Health Benefits Act set up a program in which 80% of the costs of outpatient psychiatric treatment, including psychoanalysis, have been reimbursed under the terms of the contract between the Civil Service Commission and the two major underwriters of this program, Aetna and various Blue Cross/Blue Shield plans. This program (Federal Employees Health Benefits Program—FEHBP) has enabled millions of federal employees, whose incomes would otherwise have excluded them, to consider psychoanalysis as a treatment option.
Additionally, third party payment programs facilitated a consumer-oriented approach among providers of
services and stimulated a proliferation of new mental health care plans. Health Maintenance Organizations (HMO's) have arisen throughout the country and have provided prepaid mental health care for subscribers. The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), “Medicaid” and “Medicare” programs also include prepaid systems of mental health care for specialized segments of the population. The Community Mental Health Center movement derives the largest proportion of its financing from third party sources, Finally, and perhaps most important to psychoanalysis, pending federal legislation establishing a National Health Insurance Program is almost certain to be enacted and put into effect in the foreseeable future.
All of these programs have operated with the concept that persons with illnesses of psychological origin have a “right” to the most appropriate and effective method of treatment, delivered in a timely way, and at a cost within the means of the prospective patient. Heretofore, mental health care delivery systems have been subject to the same problems as have beset general health care systems: namely, the high cost of services, spotty access to sources of care, and insufficient attention to prevention of illness, especially as reflected in inadequate health levels among lower socio-economic groups of the population. Public clamor for improved delivery systems has raised questions about a potential disturbance in the balance between individual (personal) and collective (societal) responsibility for mental health in any future NHI program. If greater weight is given to the former, society may preserve freedom of choice for some at the expense of perpetuating health care “insecurity” for many. On the other hand, emphasis on governmental responsibility for mental health care delivery, while enhancing health care security for the majority, may be purchased at the expense of individual choice for some.
The assertion of the right to treatment and its impact on mental health care delivery systems may be of only peripheral concern to most psychoanalysts. In our practices, the issue is often not so much whether adequate treatment is or is not available, but whether psychoanalysis is more appropriate for a particular patient than other therapies. However, third party payers have raised questions which do promise to bear directly on the private practice of psychoanalysis.
In the past several years, third party payers have become increasingly concerned with cost-effectiveness factors in their subscribers' utilization of coverage for long term, intensive psychoanalytic psychotherapy and psychoanalysis. Conclusions drawn from statistical studies of the utilization of psychoanalysis and other long term psychotherapies by persons covered under their high option insurance programs led CHAMPUS and the D.C. area “Blue” programs to announce plans to reduce benefits payable for private, outpatient psychiatric treatment in 1974. A concerted public information program, together with conferences among insurance officials, certain legislators, and representatives of both national and local organizations of psychiatrists and psychoanalysts, plus a flood of letters to appropriate officials from subscribers protesting the proposed cutbacks, persuaded these insurers to defer implementing their proposals. This success, although encouraging, did not resolve the issue, since a few months later Aetna quietly did markedly restrict its coverage of outpatient psychiatric treatment. The extent to which Aetna's decision will establish a precedent for other insurance programs remains to be seen.
At this time, the American Psychiatric Association is participating in a statistical study to determine the utilization of FEHBP mental health benefits in the Washington, D.C. area and in two other areas of the country. Statistics already available suggest that the percentage cost of mental health benefits under the FEHBP has leveled off in the past five years at between 7.0-7.5% of total benefits paid for all types of services. This finding may have quashed an earlier prediction of insurers that utilization of mental health benefits, then increasing at a rate of about 10% per year (1965-1970), would ultimately bankrupt the program unless steps were taken to reduce coverage. Of potentially greater significance to legislators planning a National Health Insurance program is the statistic that 0.6 percent of people covered under FEHBP are receiving 7.4% of the total benefits paid.
An inference that could be drawn from this latter statistic is that 99.4% of subscribers are supporting the outpatient psychotherapy and psychoanalysis of a minuscule few. Although this criticism can be readily countered with the argument that an even smaller percent of subscribers benefit from coverage of the high costs of rental dialysis or organ transplant surgery, the more important issue to the insurers is whether the effectiveness of the long term intensive psychotherapies (including psychoanalysis) justifies their cost. Sentiment and opinion against including benefits for psychoanalysis in major medical insurance programs seem, in part, to reflect a deeply rooted prejudice against psychoanalysis,
one with which most psychoanalysts are familiar. It is doubtful if this source of bias can be significantly modified by educational activities of individual analysts or their professional organizations. However, another source of the inclination of insurers to exclude or severely limit coverage is ignorance on their part about what psychoanalytic treatment is, who is qualified to provide it, what sort of psychological problems are appropriately treated by it, and what mechanisms exist for assuring the accountability of its providers for quality control and outcome evaluation. This area of bias seems most usefully approached via educational techniques both on a person-to-person and on professional organizational levels.
Arguments frequently advanced to counter the cost-benefit critique of inclusion of the long term psychoanalytic psychotherapies under third party payment systems include: (1) Higher alternative costs. (Inadequately treated individuals may require lengthy or repeated hospitalizations, show increased incidence of “somatic” illness, and be less productive in society than adequately treated individuals.) (2) Humanitarian considerations. (Since neurotic pain and suffering is anachronistic and, from the viewpoint of contemporary reality, needless, long term psychotherapy and psychoanalysis is justified by its relief of such suffering, and by its concurrent enrichment of a person's life through facilitating the development of his full potential.) (3) The principle of distributive justice. (Since the potential for the “pursuit of happiness” should be equally distributed among all, and since some are unable to achieve personal fulfillment as a consequence of psychological problems which can be (potentially) alleviated by psychoanalysis, then our society has an obligation to provide such treatment, in order to insure a more equitable opportunity to all its citizens to pursue their inalienable rights.)
Despite the admirable idealism explicit in these arguments, they have had less than outstanding success in convincing statistically-oriented insurers to abandon their guiding measure: the effectiveness of psychoanalysis vs. its cost and the limited number of people treatable by analysis. A potentially greater effect in modifying the “anti-psychoanalysis” position taken by third party payers and by certain legislators could result from presentations to appropriate officials of: first, convincing and carefully documented demonstrations of the effective outcome of psychoanalysis as contrasted with and differentiated from other forms of treatment; and, second, the feasibility and usefulness of analytic peer review and utilization committees. The success of such presentations may depend in part on thoughtful consideration of our position on the subject of “models” of psychological illness.
The concept of the “medical” model of mental illness is derived primarily from sociological studies describing deviant behavior which is negatively valued by society and characterized by the attributes of organicity, non-voluntariness, and by the assumption on the part of the person so afflicted of the social role of “patient.” Third party payers seem to have subsumed this model in determining eligibility for mental health benefits as exemplified in forms distributed to providers. Such forms request information on specifically identifiable symptoms or abnormal behavior, and the extent to which they are disabling to the subscriber; identification of specific etiological agents; a diagnosis conforming to the Diagnostic and Statistical Manual of the American Psychiatric Association (D.S.M. II); and a prognosis or estimate of the duration of treatment. Many analysts have been hard pressed to conscientiously and accurately describe their analysands by these “third party” criteria. In the traditional “two-party” health care system, a “patient” was defined operationally as any individual seeking and accepted for analysis, whatever his symptomatic manifestations, his diagnostic category and etiologic considerations. In addition to the considerable threat to the confidentiality of the treatment relationship, third party efforts to scrutinize and evaluate the extent to which psychoanalytic patients fit the so-called “medical” model challenge, for some analysts, the very premises of their selection of patients and justification of psychoanalytic treatment. (It may need explicit mention that the necessary truthfulness on the part of either partner may be violated at the outset, irreparably damaging the analytic relationship).
Contemporary psychoanalytic clinical theory has not aspired to adhere closely to a “medical” model of human psychological suffering. We have viewed psychopathology as more faithfully understood and treated via “developmental” models. Briefly, such models postulate a temporal sequence of interrelated psychological events unfolding in the course of the maturation and development of the human organism from birth (or before) onward throughout the life of the individual. A more crucial part is thought to be played by events during certain periods in determining the “normality” of the person's psychological development and contemporary behavior. Also, we consider behavior to lie on a continuum from normality to abnormality; the latter, in part, socially defined. Thus, in any analytic patient there may be no sharply defined criteria distinguishing psychopathology from psychic health. Mental illness according to a “developmental” model is viewed as behavior “quantitatively” as well as “qualitatively” different from socially accepted norms.
The psychoanalyst's use of a “developmental” model may also affect the goals established for analytic treatment. Although the patient coming for psychoanalysis is most often consciously seeking symptom relief or alleviation of various types of psychic “pain,” the analyst usually recognizes that an analytic “cure” may not be achieved short of a major modification and reintegration of the analysand's character structure, a goal the patient himself may not share with his analyst at the outset of treatment. In practice, it seems probable that in some instances an analyst might utilize a “medical” and in others a “developmental” model, or an amalgamation of both, in his evaluation and recommendation of psychoanalytic treatment for individuals seeking his help. However, the extent to which the analyst employs a “developmental” model will make for essential differences between his own practice and that of non-analytic practitioners. It is in recognition of the importance of educating third parties to the nature of these differences that various committees devoted to this end have recently been established in our professional organizations.